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Inspection on 29/12/05 for Olivia Residential Care Home (2)

Also see our care home review for Olivia Residential Care Home (2) for more information

This inspection was carried out on 29th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A new resident has recently moved into the home she said that she is very pleased with her new home, that the staff treat her well and everything is "just so". She said that friends have visited her over the Christmas period and she enjoyed Christmas dinner. The registered manager is Polish and the home is much influenced by Polish language, food, religion, media and culture. This meets the needs of residents ideally, as some are Polish. Arrangements are in place to ensure that all the resident`s health care needs are identified and met.

What has improved since the last inspection?

Over the last calendar year the home has had four inspections from the Commission. There has been a number of improvements during this time including all bedrooms being fitted with call bells, the development of a Statement of Purpose and Service Users Guide, the registered manager has completed the Registered Managers Award and NVQ level 4 in Care and a Fire Officer visited the home to assess the fire procedures, equipment and systems. Eight new fire doors have been fitted in the home and fire risk assessment has also been completed.

CARE HOMES FOR OLDER PEOPLE Olivia Residential Care Home (2) 7 Beechcroft Avenue New Malden Surrey KT3 3EG Lead Inspector James O`Hara Unannounced Inspection 29 December 2005. 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Olivia Residential Care Home (2) Address 7 Beechcroft Avenue New Malden Surrey KT3 3EG Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8949 1701 020 8949 1701 Mrs Lucja Bart Mrs Lucja Bart Care Home 6 Category(ies) of Dementia (6), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (6), Old age, not falling within any other category (6) Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2005 Brief Description of the Service: The home is situated in a quiet residential area, yet close to both local amenities and town centre facilities. The home is much influenced by Polish language, food, religion, media and culture. This meets the needs of residents ideally, as some of the residents are Polish and it is clear that this influence is much valued by those who live here. It should be noted that the service is not exclusive to residents from Poland, but any prospective residents should be aware of the influence of Polish culture in the Home. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 9.30am and finished at 11.am on a Thursday morning. The registered manager was not present however the registered managers daughter and husband ably supported the inspection process. Methods of inspection included, previous inspection experience of the home, observation of contact between staff and residents and discussion with three residents. Records examined included staff files, Criminal Records Bureau Checks, staff training records and fire safety records. Previous requirements and recommendations were discussed with the registered managers daughter. What the service does well: What has improved since the last inspection? What they could do better: There was a two requirements and three recommendations set at the last inspection. The registered managers daughter provided evidence that one requirement had been met but was unable to evidence that the other requirement had been addressed. As a result of this inspection there are two requirements and four recommendations. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 6 The overall impression when visiting the home is that it is well managed however the home still needs to develop a fire safety procedure and ensure that all staff is aware of this procedure. The home should also ensure that regular quarterly fire drills occur and all members of staff attend training on Fire Safety. The continuity of care is undoubtedly one of the home’s strengths however given that the home has increased the number of residents living at the home the staffing levels need to be reviewed. The inspector would like to thank the service users, the registered managers daughter and husband and staff for their support on the day of the inspection. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Standards 1, 3, 4 and 5 were assessed as met at the last inspection. The home provides prospective residents and their representatives with the information they need to make an informed decision about whether or not to use the service. EVIDENCE: The registered manager is Polish and the home is much influenced by Polish language, food, religion, media and culture. This meets the needs of residents ideally, as some are Polish. One new resident has moved into the home since the last inspection. The new resident is not polish. The registered managers daughter said that the registered manager met the resident at her previous home to carry out an assessment before she moved into the home. The registered managers daughter said that the service users care manager was involved in the move. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 9 The resident said that she is very pleased with her new home, that the staff treat her well and everything is “just so”. She said that friends have visited her over the Christmas period and she enjoyed Christmas dinner. Two other residents said that they enjoyed Christmas at the home, one said that she had her own Christmas tree in her bedroom and had received some nice presents, one of these a jumper she was wearing. Both residents said that they enjoyed Christmas dinner. The home does not offer intermediate care. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8. Standards 7, 8, 9 and 10 were assessed as met at the last inspection. Suitable arrangements are in place to ensure that the resident’s health care needs are identified and met. EVIDENCE: The new resident is receiving regular daily support from the district nurse to monitor the condition of her legs. The district nurse also tends to other residents at the home. The registered managers daughter said that the home has a good relationship with the General Practitioner and the district nurse. It was noted at the last inspection that all residents have an individual plan of care that is generated on admission and developed throughout the residents stay. Records revealed care plans are subject to regular review, seeking the views of all appropriate parties. The quality of information recorded by staff was generally good. Reviews involved all relevant parties, including residents, family members or representatives, key-workers and Care Managers. There was evidence that a Chiropodist visits the home every three months and an Optician and a Dentist visit on an annual basis or sooner if need be. The registered managers daughter is a qualified occupational therapist. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 11 Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12. Standards 12, 13, 14 and 15 were assessed as met at the last inspection. Residents are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. EVIDENCE: It was recommended at the last inspection that the home record social activities attended by the residents. The registered managers daughter explained that the resident’s activities are now recorded in their daily notes. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0. Standards 16 and 18 were assessed as met at the last inspection. EVIDENCE: No complaints have been lodged with the Commission for Social Care Inspection in relation to the service in the last twelve months. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0. Standards 19, 20, 21, 22, 23, 24, 25 and 26 were assessed as met at the last inspection. EVIDENCE: Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The home is run as a family business, the registered manager is supported by her daughter a fully qualified occupational therapist and a member of staff who lives in. EVIDENCE: One member of staff has left and a new member of staff has started work at the home since the last inspection. The member of staff said that the registered manager had taken her passport to copy for the staff file. The registered managers daughter provided a Criminal Records Bureau Check and two written references for this member of staff however one of the references was completed on plain paper. It is recommended that wherever possible the registered manager must ensure that all staff references are requested on the referees company headed paper and or include a company stamp. The staff file should also include all information as required in Schedule 2 of the National Minimum Standards. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 16 It was recommended at the last inspection that the registered manager send a copy of the homes staffing rota to the Commission For Social Care Inspection. The continuity of care is undoubtedly one of the home’s strengths however given that the home has increased the number of residents living at the home the staffing levels need to be reviewed. There was three staff on duty at the time of the inspection. The registered managers daughter produced the homes staffing roster, the roster indicates that staff work the same hours each week. The roster does not indicate what arrangements are in place should any staff take annual leave or go off sick. It is recommended that the registered manager develops a weekly roster that indicates the hours worked by staff, the name of the staff and the job role of the staff. The registered manager should send a copy of the homes staffing roster to the Commission upon completion. It was recommended at the last inspection that a training programme be developed for the home to include Food Hygiene, First Aid, Fire Safety, Moving and Handling, Medication, Health and Safety and Protection of Vulnerable Adults. The registered managers daughter said that she was not sure if this had been completed. The registered manager must send a copy of the homes training program to the Commission upon completion. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38. The home appears to be well managed whilst maintaining an atmosphere of calm and conviviality however the health, safety and welfare of residents could be compromised unless fire safety procedures are set in place for the home. EVIDENCE: A requirement was set at the last inspection that the registered manager must complete a fire safety procedure for the home and ensure that all staff is aware of the procedure. The registered manager must ensure that regular quarterly fire drills occur in the home and records of these are kept in the home and all members of staff must attend training on Fire Safety. The registered managers daughter said that she was not sure if the registered manager had completed the fire safety procedure for the home. Records did not indicate that quarterly fire drills occur in the home and staff has yet to attend fire safety. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 18 The registered manager must write to the Commission indicating how she plans to ensure that all aspects of this requirement are addressed. The registered managers daughter produced the fire safety record book. Weekly fire safety checks on the homes smoke detectors are not being carried out at the home. The registered manager must ensure that the homes four smoke detectors are checked on a weekly basis. As the registered manager was not present on the day of the inspection Standard 35 will be assessed at the next inspection. As required at the last inspection the registered managers daughter produced a Landlords Gas Safety certificate for the home dated 23/09/05. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38. Regulation 23 (4) a. Requirement The registered manager must: • complete a fire safety procedure for the home and ensure that all staff is aware of the procedure ensure that regular quarterly fire drills occur and records of these are kept in the home ensure that all members of staff attend training on Fire Safety. Timescale for action 31/01/06 • • 2. OP38. 23 (4) a. the registered manager must write to the Commission indicating how she plans to ensure that all aspects of this requirement are addressed. The registered manager must 31/01/06 ensure that the homes four smoke detectors are checked on a weekly basis. • Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP29. Good Practice Recommendations It is recommended that wherever possible the registered manager must ensure that all staff references are requested on the referees company headed paper and or include a company stamp. The staff file should also include all information as required in Schedule 2 of the National Minimum Standards. Given that the home has increased the number of residents living at the home the staffing levels need to be reviewed. The registered manager should send a copy of the homes staffing roster to the Commission upon completion. A training programme should be developed for the home to include Food Hygiene, First Aid, Fire Safety, Moving and Handling, Medication, Health and Safety and Protection of Vulnerable Adults. The registered managers daughter said that she was not sure if this had been completed. The registered manager should send a copy of the homes training program to the Commission upon completion. 2. 3. 4. OP27. OP27. OP30. Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Olivia Residential Care Home (2) DS0000013427.V271636.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!